A student once complained that no horse was too dead for me to stop beating it. Long time readers are familiar with that here. Over the years I have said that the best way to prepare for a pandemic — or any other grave threat to our communities — is to strengthen its public health and social service infrastructures. While some progress along those lines have been made (the additional training and upgrading of the national laboratory system is what allows us to find swine flu cases), in the main public health and social services have continued to deteriorate and weaken. And with the day of reckoning possibly just around the corner, we are still not facing the problem:

The mild nature of swine flu infections that have been reported to date outside of Mexico may be undermining efforts to get the public to prepare for a range of pandemic scenarios, some experts in public health say.

Some officials are already facing accusations that they are exaggerating the threat of the swine flu situation.

?Some people are alleging that we?re hyping the threat. That?s not the case,? said Dick Thompson, a spokesperson for the World Health Organization.

?What we?re trying to do is to provide the best information possible. To gather that information and to provide it to the public. Because that?s the best defence, is to have information.? (Helen Branswell, Canadian Press via Edmonton Sun)

I’ve been critical of WHO lately, but I think this is completely on target. Let me extend the argument. I am really repeating what I said earlier today about the Big Picture, but in light of these observations by WHO’s Thompson it needs to be said again. And again.

What’s important about this virus is its genetic novelty. As far as we know, the human population doesn’t have any natural immunity to it. But what people perceive about the virus is its lack of novelty. Clinically it seems a lot like what they are used to with seasonal influenza. It’s not (so far) the monster of 1918 and doesn’t have the virulence of H5N1. What they are forgetting is what the genetic novelty might mean.

Because there is no natural immunity to this virus, even though clinically it appears to be like garden variety flu to the individual, with respect to the population it has the potential to spread faster and many more people sick than seasonal flu. And remember, seasonal flu is not a walk in the park. It kills an estimated 30,000 people a year.

A bad flu season can fill hospital emergency rooms and in patient beds to the bursting point. We currently have fewer staffed hospital beds per capita than we did in the last pandemic, 1968 (the “Hong Kong flu”). There is no reserve capacity. We can’t just add physical beds. Beds don’t take care of patients. Nurses and doctors do.

Now take a bad flu season and double it. To each individual it’s the same disease but now everybody is getting it at once, in every community and all over the world. In terms of virulence, it’s a mild pandemic. It’s not a lethal virus like 1918. But in terms of social disruption it could be very bad. If twice as many people get sick, the number of deaths could be 80,000 in the US instead of 40,000. Gurneys would line the hallways of hospitals and clinics. And absenteeism amongst health care workers would compound the problem. Infrastructure would probably survive intact. No need to have your own water supply or electricity generator. But it would be a very rough ride.

All of this could plausibly happen from this virus without it causing anything more than the usual case of influenza. We are pouring tens of billions into infrastructure. I’m a big fan of high speed rail. But the public health and social services infrastructure — good, job producing infrastructure — needs attention and needs it right away because of this virus.

Comments

Said another way… A lot of folks are beginning to think and post that the response of public health authorities to this virus is over the top. Let’s remember what we’re trying to do, even if the virus is mild from a “life threat” perspective.
What does seem clear, is that many, many of us, probably more than normal, will be susceptible to this virus. If too many of us get it at once, we will likely overwhelm our health care delivery systems, and have too many “out sick” at one time. If health care delivery, which already has very little excess capacity is overwhelmed, then more of those who would be fine with just a little help end up not fine because there is not enough help to go around. If too many folks are out sick, our supply chains and infrastructure begin to experience breakdowns, which has its own cascade of difficulties.

So, all of the hype is for the purpose of causing fewer people to have the disease at the same time. To stretch out the period of infection spread through preventive, social distancing measures, and thereby decrease the number needing help at any given time by doing so. In graphic terms, we’re going to flatten out and lengthen the bell curve. We don’t want this to happen too intensly, we want to spread out the stress on our systems. Preventive measures and social isolation will do that.

The responsible citizen will work hard during this period to decrease the likelihood that they get infected and increase the likelihood that they do not pass an infection. In many cases these efforts will fail in the long run, but win in the short run, thus lowering the number needing help at any moment in time.

Social distancing and personal sanitary precautions are the behaviors of responsible citizens. Please accept this as an invitation to look for ways to decrease disease vectoring in your daily movements over the next few months. If you want to creatively think through this challenge and create a personal or organizational plan to do that, read this blog post as a starting point: http://innovationblogsite.typepad.com/newandimprovedinnovation/

Amazing how many people see this epidemic as a business opportunity. I’d point to the (business pop-psych, non-flu-related) book of yours that your blog is promoting, but I don’t want to give you the traffic.

So when a novel virus goes to ground, where does it go? Does it have to romp through the whole human population or is there some other way to settle it down? Sort of like the question “what if they held a war, but no one came?” What if there’s a virus out there, but everyone is off in quarantine? Does the virus eventually give up an disappear or does it morph into something less novel or what?

Sorry Crow. Not the intent. We’ve done a huge amount of thinking in this area over the last 4 years, and we share it gratis. We fund our pro-bono work with our corporate work.

I just don’t have the time to be circumspect, so am not playing any game and just offering up the info. Anyone can take it now and facilitate their own BCAP, or use the same planning process I’ve described with their family. Some have questions and I cannot keep up with all of flublogia. I’m Adirondack Mountain Man elsewhere, and a long time hard working volunteer contributor to the pandemic mitigation community. I’d hate to see folks discount the value of what I say above because I inadvertently offended you.
Peace!

Texas Reader
One of the favorite sites of the influenza activist community is http://www.getpandemicready.org/
The server it’s on is getting a lot of stress, so be patient.

It is one of the cleanest and least political. Ypu’ll find answers to your questions there easily. More comprehensive is fluwikie.com, but I sometimes feel like we “overbuilt” it. But. EVERYTHING is there if you poke around.

Texas Reader: I’m your neighbor. I had a 3 week flu nightmare back in the mid-90s. I’d hate to imagine that if I was single though my parents would have taken care of me. I don’t know what else you can really do.

Another symptom that the Dallas Morning News will end up dead sooner rather than later is that they don’t have the FW ISD story up – the Star Telegram does.

The best thing to buy and eat is Kim-Chi the Korean relish (spicy pickled cabbage). During the bird flu, some people in Asia ate it and fed it to ducks that had avian flu and they got better a lot faster and didn’t die. So I have many jars of it in my cupboard and the homemade kind bought at a Korean market. I like it, I eat it with everything now.

Sound better prepared than most, Tex. Know the symptoms of pneumonia and have a doctor or ambulance ready to call if you get pneumonia, IMO. I’d think a humidifier might help but just a guess on my part.

Speechless: I’ve proposed the same thing offline, but revere is right, people are too selfish to make quarantines work and they only make the problem worse.

That http://www.getpandemicready.org/ site is a good one.
But I have a question about one thing they said: “In a severe pandemic, according to the CDC, all family members in the household will be asked to stay at home and avoid going to work or the store if a family member is sick, for at least 7 days after the last person started showing symptoms. ”

Let’s say family member A gets sick and then recovers. Then B and later C get sick. Why can’t A be able to go to work and the store 8 days after he started having symptoms? A should be immune at that point, right?

snogger, I don’t know about your figure for the worldwide flu deaths, but I think you have a good point that when we quote figures we should be specific about the basis of the figure.

The US is such a geographically large country that we tend not to think across our borders just because most of us don’t bump into the borders often.

There are also some issues with reporting systems in some countries, so sometimes the US figures (or other 1st world country) are more reliable. But if a US only figure, we should make an effort to say so.

Correct me if I am wrong, but presumably another concern is that with the genetic novelty, the more people that get infected, the more chance there is of the strain mutating into something a lot worse.

A very, very simple point, to illustrate the nature of the problem, here. You will read it here, first. Promise. I am very confidant of that. You will encounter much useful information here, first. That is the nature of Revere’s site.

Keep your gas tank full. Top it off. Always. Why? Are you going somewhere? Are you looking for a place to escape to? No. As the pandemic advances, more and more lower level people will be infected (we are talking strictly socioeconomic status, here). That is inevitable. How many service stations are there, in your community? What will happen, when the employees begin to get sick, and cannot report to work? What happens when the employer cannot replace these people, because no one wants to be in a high capacity, clerk to customer risk encounter, here? No clerks…no gasoline. Wrong? Very simple. The stations that remain open will have lines of vehicles around the block. I was witness to this, in the early 1970’s, when the Middle East oil was sharply curtailed. If you were not there, then you have no idea; but I promise you that you will see the very same phenomena, hugely extrapolated, very soon. If you are going somewhere, you will need gasoline. Keep your vehicles topped off. Very simple stuff. Also very important. There will be more, later.

Speak up, Lisa; tell them what they need to do. You can do so, better than anyone. This is what you were made for. You are rightfully considered to be a sound voice, here (as I have always known you to be; and as Revere always knew, also); tell them what they need to do. You have a sterling, unassailable voice, here. They trust you. As is appropriate. As they should. As I do. Do your job, Lisa. This is your time. And no one can possibly do it better.

yes, it is possible it could mutate into something else. But, we may have some ways to affect which of those mutations are successful.

In an environment where there are many many susceptible social contacts, the virus that can replicate and jump into a new host the fastest is going to have the best chance of surviving.

In many cases, a ‘fast’ virus turns out to be hard on the host because the viral load rises quickly and the immune system has less time for a well-modulated response.

But, in an environment where people have few susceptible social contacts, such a virus will burn out in its current host before it gets passed on–because the host gets too sick to interact with others, before the virus has found its next host.

This is observed in the late stages of past pandemics when the viruses seem to become less aggressive. In that situation, most people have become immune to the virus, so even if someone has a lot of social contacts, only a few are infectable. Aggressive viruses make their hosts symptomatic before the dinner party instead of after it, so the host stays home.

This is one theory about why the nastier strains die out toward the end of a pandemic, leaving the watered-down descendants of the pandemic bug to become the dominant seasonal flu in following years.

To the extent social distancing can simulate the end-stages of a pandemic, by reducing a nasty virus’s chance to move on before it makes its host too sick to encounter other potential hosts, social distancing can alter the evolution of a virus, keeping it comparatively mild.

In theory. But it seems like a good theory to try to prove, by implementing social distancing as early as possible.

“The L.A. Times says we have nothing to worry about. They say that this virus is even less severe than regular seasonal flu.”

My speculation tends to consent with this observation only if it has remained on H2H transmission. But if the virus transmits to pigs, then it will be a different story. Therefore, the strict scrutiny on pig farms’ operation to avoid the re-infection of pigs’ maybe will prevent the second wave which is presumably more dangerous.

I have to wonder how much the severity of some of the cases is being under stressed so as not to cause more panic. Its clear from the USA cases that this isn’t causing a high CFR from the confirmed cases. And there are reportedly only 5 cases in the US that have resulted in hospitalization.

But going by the UK cases, things seem slight more severe. Here we have 5 confirmed cases which are: A married couple aged 27 and 24, a man aged 22, a woman aged 41 and a girl aged 12.

The married couple have now been in hospital for 4 days, and according to the BBC news channel, the 22 man was being admitted to hospital last night. While the 41 year old woman and 12 year old girl are reported to be recoving well at home.

Three out of 5 cases serious enough to require hospital treatment seems to myself like a high rate. And then when the cases that seem to require hospital treatment are the ones in their 20’s, it seems that this still could be a lot more serious than seasonal flu.

Also these cases (and it seems anybody with any Flu symptoms) are being given Tamiflu, so how much more serious would they be if they hadn’t of been given that. Like seems that maybe was the case in Mexico in the early stages when most of the deaths were being reported.

And then the CDC website has the following sentence on it “The more recent illnesses and the reported death suggest that a pattern of more severe illness associated with this virus may be emerging in the U.S.”

So are the more recent cases in the U.S (other than the death) more serious than earlier ones? Or is that just because they are now concentrating on the more severe and as reported in New York, only testing the more servere cases?

Matt: “And then the CDC website has the following sentence on it “The more recent illnesses and the reported death suggest that a pattern of more severe illness associated with this virus may be emerging in the U.S.”

Last Saturday, I commented:

“I have a speculation about the different CFR between Mexico and the United States, I have no evidences on this speculation; it is based on my experience in shrimp resistance to viral infections and related research.

I guess that the virus has been originated from the United States for a while, perhaps has circulated a decade or more in the United States, and it has caused seasonal flu sometimes. This virus is not tropical type, and it has been introduced by human or swine to Mexico lately. The pig farm with huge numbers was the first incubator and it was permeating from the farm and infecting people.

If the people in Mexico who have never traveled to the United States and their immunity are naïve to this virus, then the CFR are higher than the patients who are long time exposed to this virus.

Therefore, the record of the infected patients who died had lived/ or not in the United States could be a clue to compare. Later the sequencing and molecular evidence maybe can tell the possibility.”

——————————————
I hope that CDC can coordinate with USDA to investigate the infection path between the pig farms and people. It will conducive to the prevention of the spreading of this disease if any.

“The L.A. Times says we have nothing to worry about. They say that this virus is even less severe than regular seasonal flu.”

My speculation tends to consent with this observation only if it has remained on H2H transmission. But if the virus transmits to pigs, then it will be a different story. Therefore, the strict scrutiny on pig farms’ operation to avoid the re-infection of pigs’ maybe will prevent the second wave which is presumably more dangerous.

We still don’t have good data to conclude this virus is ‘nothing to worry about’. It’s looking more hopeful with the US data, but if Matt’s information about the British (suspected? lab confirmed?) cases proves correct–well, that’s the problem. Not enough consistent data yet to say *what* is going on with the severity of this critter.

Add to that the observation that with H5N1 ‘bird’ flu, some people haven’t progressed to a ‘cytokine storm’ complication until day 10 of their illness (albeit after already having symptoms requiring hospitalization); many of these first H1N1 cases haven’t yet been sick that long. The fact that most aren’t in the hospital strongly implies the illness is going to remain mild. But it isn’t a guarantee.

For some answers, we have no choice but to wait.

Meanwhile in an abundance of caution, lets do the social distancing thing, school closures, etc.

Dylan’s right about the gas thing. As a general emergency preparedness principle, it’s good to fill up when you hit the ‘halfway’ mark on your tank instead of waiting until you’re ‘empty’. Works for pandemics, works for earthquakes, works for tornado outbreaks, etc. Good general advice.

I wish the LA Times wouldn’t quote one person’s computer model. In Computer Science, we have a concept (as do other disciplines) of Garbage-In-Garbage-Out (GIGO).

We have no idea what the real CFR or transmission rates are – Dirk Brockmann just did some WAGs (Wild Assed Guesses – another term we use). That’s the Garbage In.

Once we have educated guesses on these rates then computer modeling is a worthwhile exercise but right now, they are virtually useless. The other approach would be to model best and worst case and then get a range. His numbers really seem like best case to me.

Lisa – your post are usually great, but Tornado outbreaks? As a resident of Tornado Alley, tornado damage is always relatively localized – much more than you think. Even a rare EF5 twister isn’t going to have a major impact on the gas supply unless you live in the middle of nowhere with only one gas station for miles around.

I take the opposite opinion on the gas. The less you fill up in a pandemic the better. A gas pump is the perfect vehicle for transmission – people might be standing around coughing on it. The less you touch it the better.

Of course, I telecommute so if I didn’t go to the gym every day, I could stretch out a tank for a couple of months.

Lisa the GP: The five cases that I mentioned are all lab confirmed cases.

The married couple were the first cases to be confirmed in the uk on Monday. According to reports they returned from Mexico on the 21st April.

Either by time they got back to this country and soon after the Man was feeling unwell and had Flu like symptoms. Then by last wekend his wife also started to feel unwell. Then on saturday (or sunday, there seems to be some confusion about when it was) they were admitted to hospital. All comments about them say they have “Mild flu” and “responding to treatment”. But there was some talk of one of them maybe being well enough to leave hospital late on tuesday, but still they are both in hospital.

Now as it was the first case in this country, at the begining, it might have been a case of just being very caustious for why they were admitted. But if that was the case, it doesn’t make much sense for them to still be there 4 or 5 days later. When there are other confirmed cases that are being treated in their own homes.

The other three confirmed cases were announced yesterday lunch time by the Prime minister.

And they are: a 12 year old girl who arrived back from Mexico on the same flight as the married couple (but doesn’t seem to be related to them). A 41 year old women and a 22 year old man.

The girl and woman are reported to still being treated in their homes and responding well to treatment. While the 22 year old man was admitted to hospital late last night, after having first been treated at his home.

As you said, I think its still too early to draw any conclusions from such a limited number of cases. But it does make me wonder how much they are under playing how serious the cases are, so that there isn’t more panic.

What will happen, when the employees begin to get sick, and cannot report to work?

Haha. In a ‘right-to-work’, like the one I live in, they’ll come to work sick, unless they really, really can’t get out of bed. So you’ll catch the flu from the service station people before the service station shuts down.

Because pigs are growing under a polarized evolution of neglecting their natural immunity now, pigs in general are dangerous vectors when they come to the mutual host’s condition with human. Swine flu virus and MRSA perhaps have reflected the extremely unstable reservoir as vectors in pigs.

My speculation of swine flu virus; pig as the host is the actor, human beings are the supporting actors- pigs survive long before human’s existence. Swine and swine virus have been in co-evolutionary arms races for millions ( or more) years. Now, we human has intervened their natural selection by feeding them antibiotics and selective breeding on our benefits like fast growth. They are very naïve in natural immunity, so to speak.

In another metaphor, swine is the home ground of swine flu virus. By accident, the virus comes to infect us-like a tour for virus. If you let them back to their home, it is like to let tiger back to the mountain.

My next speculation is if there will have second wave or third wave like 1918; it would most likely via swine. Only H2H transmission, the virus will diminish quickly, IMHO. Virus is a good regulator anyway-it is not against us.:-)

As a Chinese proverb says, if nature is against us, we have chance to swim across somehow. But if we human is against human (unreasonable treatment on pig for instance), we only will perish.

Lisa the GP: Just wanted you to know I have also jumped on the “Home Alone” bandwagon and am emailing your informative and very helpful article to my mother and many single friends. As a single woman, know I’ll follow your excellent suggestions, too. No telling how many lives you’ve helped with that one article — either through the conveyance of knowledge, practical application, or simple preparation and peace of mind — but add about 20 more to the list! Thanks so much!

Revere(s): Same can be said for your awesome work! Kudos and thanks to you!

Matt #25 – as far as I understand it the couple here in Scotland were admitted to hospital in order to keep them under observation and restrict contact with other people, not because the illness was very bad.

“‘We may move away from case updates,’ [the CDC’s] Dr. Richard Besser said. ‘The numbers become a little murkier, and we’ll focus more on where things are occurring and what that tells us about the spread of infection.’

“The public may be surprised to know it’s not so important to have an exact tally, or to tell a person whether he or she has the germ, said Sharon Shea. She is director of infectious disease programs at the Association of Public Health Laboratories, the network of labs that work with CDC.

“‘It’s not what people want to hear. As an individual, you want to know what’s making you sick,’ she said.”

My questions: Are we about to lose transparency from the CDC, or are the numbers truly becoming meaningless? And if we aren’t getting numbers, how can the general public gage how prevalent the spread is or how serious it becomes?

Also … Is it reasonable to NOT tell patients that they have a/H1N1 if they do?

Both of these sound like significant changes in the public policy and how the spread of the disease is being handled.

Pat: I’m a big proponent of transparency, but I’m not so troubled by this. Regarding individuals, it doesn’t seem that it makes much clinical difference. Most seasonal flu cases are never subtyped and nobody complains. Nobody is covering anything up. On the contrary, they are implicitly saying: “it’s here. Let’s stop obsessing over numbers.” Knowing your subtype is almost never done for patients, anyway, even if it is known by the lab. It’s a close call, and I think I might do it differently, at least for a while, but they may be overwhelmed and short handed.

Being a data person myself, I’m going to take the opposite opinion. The data may not help this outbreak, but it will help with the next. Afterwards, people can look and see how areas that didn’t close schools, closed one school or the whole district affected the spread. And that’s just one example of how we can examine what policies worked and what didn’t. Also, it will allow better computer modeling.

I’ve worked on urban modeling before and the better your data the better your results.

This is a golden opportunity for collecting this kind of data that may never occur. The US data starts early enough to be useful. The non-US/Mexico data can start from the first patient.

Revere — Thanks for the feedback. Personally, if I became ill, I would most definitely want to know if it was “seasonal flu” or A/H1N1. If I was sure I’d already had it and therefore has some immunity should it return with a vengeance, I would volunteer to help others earlier in the crisis. But again, my preference.

Many thanks to revere and the commenters for mucho information. My question is probably speculative — how can television be used to broadcast this sort of serious information and discussion, rather than the yammering nonsense and handwaving it currently spits out, especially on the cable shows that are ostensibly political commentary but are actually entertainment?